Desquamative Gingivitis as a Clinical Manifestation in Endocrinal Imbalance - A Case Report

Headnote

Abstract

Desquamative gingivitis is not a specific disease entity but a gingival response associated with a variety of conditions. It is a condition characterized by intense erythema, desquamation and ulceration of the free and attached gingiva. This article is a case report of desquamative gingivitis occurring in a 48 year old female patient who presented with a complaint of burning sensation in the oral cavity for the past 3 years. Intra oral examination revealed shiny gingiva with intense erythema and desquamation with significant bleeding on palpation. She gave a history of menopause at 45 years, followed by hysterectomy 5 months later. Direct immunofluorescence analysis of the biopsy specimen showed negative results, ruling out auto-immune causes. Orthopantomograph showed a generalized rarefaction of the mandible. Sex hormonal assay revealed a change in levels of hormones. The present lesion could be caused by endocrinal imbalance, termed as 'senile atrophic gingivitis', seen in some post menopausal women. The patient is undergoing treatment for the systemic and gingival condition.

Key words: Desquamative gingivitis, Immunofluorescence technique, Senile atrophic gingivitis, Menopause, Estrogen.

Introduction

Chronic desquamative gingivitis (DG) was first described by Tomes and Tomes in 1894.1 In 1932, Prinz and Merrit first proposed the term of chronic diffuse DG and attempted to define the disease process.2 In 1960, however, Mc Carthy et al., suggested that desquamative gingivitis was not a specific disease entity, but a gingival response associated with a variety of conditions.3 It is characterized by fiery red, glazed or eroded looking gingiva. There will be loss of stippling and the gingiva may desquamate easily with minimal trauma. DG is more common in middle-aged and elderly females, is painful and predominately affects the buccal/labial gingiva. The condition frequently spares the marginal gingiva, but can also involve the whole thickness of the atfached gingiva. Its clinical appearance is not significantly altered by traditional oral hygiene measures or conventional periodontal therapy4,5

The clinical features of DG varies in severity and appears as mild, moderate or severe forms.6 In the mild form, there is diffuse erythema of the marginal, interdental and attached gingiva. The condition is usually painless and comes to the attention of the patient or dentist only because of the overall discoloration. In the moderate form, there is a patchy distribution of bright red and gray areas involving the marginal and attached gingiva. The surface is smooth and shiny, with the normally resilient gingiva becoming soft in consistency. There is a slight pitting with pressure and the epithelium is not firmly adherent to the underlying tissues. Massaging the gingiva with a finger results in peeling of the epithelium and exposure of the underlying bleeding connective tissue surface. Patients complain of burning sensation, sensitivity to thermal changes and inhalation of air is painful. The patient cannot tolerate condiments and tooth brushing causes painful denudation of the gingival surfaces. The lingual surface is usually less severely involved because the tongue and friction from food excursion reduce the accumulation of local irritants and limits the irritation. In the severe form, there is a scattered, irregular areas in which the gingiva is denuded and appears strikingly red. Because the gingiva separating these areas is grayish blue, it gives an overall speckled appearance. The surface epithelium seems shredded, friable and can be peeled off in small patches. A blast of air directed at the gingiva causes elevation of the epithelium and the consequent formation of a bubble. The mucous membrane other than the gingiva is smooth, shiny and may present a Assuring in the cheek adjacent to the line of occlusion. The condition is extremely painful. The patient cannot tolerate coarse foods, condiments or temperature changes. There is a constant dry, burning sensation through out the oral cavity that is accentuated in the denuded gingival zones. Desquamative gingivitis is actually a clinical manifestation caused by several disease processes and does not represent a distinct entity.78 The disease that can causes DG can be classified into 2 categories : immunological (autoimmune or auto immune like) and idiopathic. Immunological disease causing DG include erosive lichen planus, lichenoid mucositis, benign mucous membrane pemphigoid, pemphigus vulgaris, bullous pemphigoid. Idiopathic lesions are probably not autoimmune-medkted and may be caused by endrocrine imbalance, chronic bacterial, fungal and viral infections.5 The following is a case report of non-immunologic cause of gingival desquamation arising from an endocrinal imbalance.

Case report

A 48-year-old female patient (Figure 1) reported to us with a complaint of burning sensation in the oral cavity, oral discomfort and soreness of the gingiva since 3 years. These lesions limited her oral hygiene and intake of food. Intraoral clinical examination revealed shiny marginal and attached gingiva with intense erythema, desquamation and significant bleeding on palpation. The lesions were limited to the maxillary and mandibular attached gingiva with a classic desquamative pattern (Figure 2,3). The desquamative gingivitis was of moderate severity. No other swelling, ulcers or masses were noted in the oral cavity. Patient was found to have no lesions in cutaneous, nasal, ocular or genital area. Medical history of the patient revealed menopause at 45 years of age, followed by hysterectomy 5 months later. 3 years ago, she was diagnosed with hyperthyroidism and is under medication ever since. She was otherwise systemically healthy.

Since there are a wide variety of diseases presenting with DG, further investigations were needed to find the exact cause. Incisonal biopsy of perilesional mucosa was done between teeth 12 and 13 and the specimen was submitted for routine histologic and direct immunofluorescence (DIF) examination. Sex hormonal assay and an orthopantomograph (OPG) were also advised.

Histopathological report of the biopsy specimen showed a slight thinning of the gingival epithelium with a large amount of inflammatory cells in the connective tissue (Figure 4).

In direct immunofluorescence (DIF) analysis antibodies IgG, IgA, and IgM were negative. Complement CI3 and Clq were also negative. Sex hormonal assay revealed that the estrogen level was 14.32 pg/ml (normal level during menopause is 5.00 pg/ml- 54.7 pg/ml) and progesterone level was 0.31 ng/ml (normal level during menopause is 0.1-0.8 ng/ml). The follicle stimulating hormone level was 90.38 IU/L (normal level during menopause is 23.0-116.3 IU/L) and luteinizing hormone level was 54.62 IU/L (normal level during menopause is 15.9-54.0 IU/L). It revealed that the hormonal levels are in expected lines to what is seen in menopause. OPG showed a generalized rarefaction of the mandible (Figure 5).

Considering the histopathological findings, negative DIF and the results of hormonal assay we conclude that, the present lesions could be caused by endocrinal imbalance and can be termed as senile atrophic gingivitis.

The patient was then referred to Rajarajeswari Medical College where she is receiving hormonal replacement therapy (HRT) and calcium supplements. The patient then was prescribed topical steroid (triamcinalone acetate) application. However, due to the negative response to treatment even after one month, she was advised clobetasol propionate topical ointment and a topical antifungal agent, to which the gingival lesions responded well. The patient was then evaluated at 2 months, 4 months and 6 months, andoralhygienemeasureswereundertakensidebyside.In addition, no oral or skin lesions developed during the treatment and the patient did have some symptomatic relief, however, localized areas of erythema remained on the gingiva, especially in the interdental papillary region (Figure 6,7). The desquamative gingivitis had lessened in severity and was then considered mild.

Discussion

Desquamative gingivitis is a common condition. It is a clinical manifestation of several different disease processes and does not represent a distinct entity.7'8 DG is characterized by intense redness and desquamation of the surface epithelium of the attached gingival.9 Majority of cases of DG are known to be due to mucocutaneous conditions, in particular immunologic causes like lichen planus, pemphigoid and pemphigus. Other causes include endocrinal imbalance, allergic reactions to dental restorative materials, tooth pastes or mouth rinses, infections of viral, bacterial or fungal origin.5 Differentiating these disorders is important because they share a common clinical appearance but often have a different management and prognosis. Therefore, a proper diagnosis of underlying pathologic entity must be established in order to provide the appropriate therapy and prevent further progression.

However, since DG is a common clinical presentation of a variety of diseases, definitive diagnosis and treatment are problematic.1012 Routine histological examination sometimes cannot differentiate between the DG-causing diseases.13'14 Microscopically, gingiva affected by desquamation usually exhibits atrophy of the germinal and prickle cell layers of the epithelium and in some patients, areas of ulceration. In the present case, the histopathological report showed a slight thinning of the gingival epithelium with a large amount of inflammatory cells in the connective tissue.

Immunohistology, particularly immunofluorescence, is increasingly being used in routine histopathology to more accurately diagnose DG diseases.13'14 In the present case report, direct immunofluorescence of the specimen showed negative results, therefore ruling out auto-immune causes Her blood counts were normal and she had no history of allergy or infections, ruling out either of these causes.

Hormonal changes in women occur at puberty, during menstruation, during pregnancy and at menopause. Understanding the role of gingival tissues as target organs for estrogen and progesterone forms the basis for periodontal care of female patients. DG is sometimes seen in postmenopausal women or those who has undergone hysterectomy/overectomy Women over the age of 45 should watch their mouths carefully for signs of gingivitis, especially changes in gingival colour, appearance and tenderness. Symptoms of DG include gingiva that is erythematous, painful to touch, show white patches or coating and looseness of tissue. In the present case, the affected individual is a female aged 48 years, undergone hysterectomy and presents with symptoms typical of desquamative gingivitis. She therefore fits into the category of desquamitive gingivitis due to sex hormonal changes.

Estrogen affects cellular proliferation, differentiation and keratinization on the gingival epithelium. Estrogen deficiency can lead to reduction in collagen formation in connective tissue resulting in a decrease in skin thickness.15 Hormone receptors have been identified inbasal and spinous layers of the epithelium and connective tissues, implicating gingiva and other oral tissues as targets to manifest hormone deficiencies.16 Osteopenia and osteopo-rosis may also occur during menopause." During menopause, the usual rhythmic hormonal fluctuations of the female life cycle are ended due to the fact that estradiol ceases to be the major circulating estrogen. Levels of follicular stimulating hormone (FSH) and luteinizing hormone (LH) begin to rise and so the levels of sex hormones begin to fluctuate. Fluctuation of sex hormones during menopause have been implicated as factors in causing inflammatory reactions, hypertrophy or atrophy in the gingiva. The hormonal assay in the present case was typical of post menopausal changes and the appearance on the orthopantamogram showed some rarefaction, which could be due to osteopenia or osteoporosis. The treatment of this condition usually includes correcting the systemic condition and palliative treatment of the gingival condition.

Conclusion

Desquamative gingivitis is not a disease but represents a reaction pattern of the gingiva which conceals other pathological entities. Dermatoses, hormonal disturbances, chronic irritation and idiopathic causes have been incriminated as etiologic factors. Patients with condition consistent with DG should be evaluated properly and systematically, else it canlead to unpleasant outcomesi.In the present case-report, the gingival condition could have been caused by endocrinal imbalance. Supportive palliative treatment and maintaining good oral hygiene along with HRT (hormonal replacement therapy)/ERT (Estrogen replacement therapy) and calcium /vitamin D supplements were advised. Although only a small percentage of post menopausal women suffer from this condition, a better understanding of the causation and pathogenesis is necessary for the development of more successful treatment modalities and therapeutic interventions.

References

References

1.Tomes J, Tomes G. Dental surgery. 4th ed, London: Churc-hill,1894.

2.Prinz H. Chronic diffuse desquamative gingivitis. Dent Cosmos 1932;74:331-33.

3.McCarthyl FP, McCarthyl PL, Sbklar G. Chrome desquamative gingivitis : a reconsideration. Oral Surg Oral Med OralPathol 1960;13:1300-13.

4.Scully C, Porter SR. The clinical spectrum of desquamative gingivitis. SeminCutanMed Surg 1997;16:308-13.

5.Nisengard RJ, Rogers RS. The treatment of desquamative gingival lesions. J Periodontal 1987; 58:167-72.

6.Glickman I, Smulow JB. Chronic desquamative gingivitis: Its nature and treatment. J Periodontal 1964; 35:297.

7.Mariotti A. 1991. Desquamative gingivitis: revisited. Todays FDA. 1991 Jan;3(l):lC-2C.

8.Sklavounou A, Laskaris G Frequency of desquamative gingivitis in skin diseases. Oral Surg Oral Med Oral Pathol 1983;56:141-44.

9.Carranza FA Jr, Newman MG Clinical periodontology. 8th ed. Philadelphia: WB Saunders; 1996. p. 259.

10.Rogers RS 3rf, Sheridan PJ, Nightingle SH. Desquamative gingivitis: clinical, histopathologic, immunopathlogic and therapeutic observations. J Am Acad Dermatol 198277:729-735.

11.Markopoulus Ak, Antoniades D, Papanayotou P, Trigonidis. Desquamative gingivitis: A clinical, histopathological and immunologic study Quintessence hit 1996;27:763-767.

12.Wojnarowska F, Briggaman RA. Management of Blistering Diseases. New York Raven Press; 1990 105-116.

13.Nisengard RJ, Neiders M. Desquamative lesions of the gingiva. J Periodontal 1981;52:500-510.

14.Nisengard RJ, Alpert AM, Krestow V. Desquamative gingivitis: immunologic findings. J Periodontol 1978;49: 27-32.

15.Whitehead MI, Whitcroft S JI, Hillard TCB: An Atlas of the Menopause, The Parthenon. Publishing Group, New York, 1993.14.

16.American Dental Association Health Foundation Research Institute, Department of Toxicology. Antibiotic interference with oral contraceptives. J AmDent Assoc 1991; 122:79.

17.Wactawski-Wende J, Grossi SG, Trevisan M, Genco RJ, Tezal M, Dunford RG, et al. The role of osteopenia in oral bone loss and periodontal disease. J Periodontol 1996 Oct; 67(10 Suppl):1076-84.